Hearing loss and
subjective tinnitus loudness
Most patients who experience tinnitus also have some form of hearing
loss, but not all patients with hearing loss have tinnitus (Nicolas-Puel et al. 2002; Tyler & Baker 1983;
Mazurek et al. 2010). The strong relationship between tinnitus and hearing impairment probably
explains why, in the UK, 82% of tinnitus patients are referred to Audiology
departments (Gander et al. 2011). To
complicate matters, some people with clinically normal hearing have tinnitus (Aazh et al. 2011) suggesting that hearing loss per se not be
the dominant factor for induction of tinnitus.
A common concern
expressed by patients is that although they can cope with the current level of
their tinnitus, one of their fears is that if their hearing worsens it may lead
to an increase in tinnitus loudness that they would not be able to cope with.
Audiologists typically reassure patients by explaining that there is no direct
relationship between severity of hearing loss and tinnitus loudness. There are
many people with clinically normal hearing who experience very loud tinnitus
and people with very severe hearing loss, but no tinnitus. A compelling counter
argument is people with acute hearing impairments such as an impacted wax, ear
infections, acute noise exposure or those wearing hearing protection experience
an increase in tinnitus loudness. Consistent with this view is the observation
that ear plugging leads to decreased loudness tolerance (Formby et al. 2003).
Therefore, it is reasonable to assume that hearing loss severity is
related to tinnitus loudness, an interpretation that is consistent with some
central gain models of tinnitus and hyperacusis (Eggermont &
Roberts 2004; Chen et al. 2015; Auerbach et al. 2014).
A recent analysis
conducted by Dr. Aazh’s tinnitus team on the data for approximately 1500
patients showed that impact of tinnitus on patient’s life as measured via
Tinnitus Handicap Inventory (THI) (Newman et al. 1996) is weakly but significantly correlated with
average hearing thresholds across ears, correlation coefficient (r)=0.13
(p<0.001) (Figure 1). However this
analysis doesn’t take into account the intervening effect of other factors. Therefore,
it is not clear whether the relationship between hearing loss and tinnitus
remains statistically significant, if the effects of other variables known to
impact tinnitus are taken into account (e.g., depression, anxiety etc).
In a pioneering
study, Dr Aazh’s tinnitus team assessed the relationship between tinnitus
loudness and pure tone hearing thresholds while taking into account the effect
of other factors among over 400 patients with tinnitus and hyperacusis (Aazh & Salvi
2018). This is study is published in the Journal
of the American Academy of Audiology.
Hearing loss and other predicting factors for tinnitus loudness
To determine the
contribution of other factors in Tinnitus Loudness as measured via visual
analogue scale (VAS), we performed a stepwise linear regression analysis that,
in addition to PTA threshold of the better ear, included the PTA threshold of
the worse ear, ULLmin, VAS of Tinnitus Annoyance, VAS of Tinnitus Life Effect, Insomnia
Severity Index (ISI), THI, Hyperacusis Questionnaire (HQ), Hospital Anxiety and
Depression Scale-Anxiety subscale (HADS-A), HADS-D (Depression subscale), age
and gender in the linear regression model.
Nine variables did
not significantly increase the proportion of variance predicted by the
regression model hence were removed from the model. These were the HADS
depression score (p = 0.35), PTA
thresholds for the worse ear (p =
0.47), THI score (p = 0.31), HADS
anxiety score (p = 0.65), ULLmin (p = 0.79), HQ score (p = 0.58), ISI score (p = 0.8), age (p = 0.08), and gender (p =
The remaining three
variables in the stepwise linear regression model that increased the proportion
of variance accounted for by the model are shown in Table 1. Tinnitus Loudness was significantly associated
with PTA Threshold of the better ear (t = 3.16, p<0.001, regression
coefficient: 0.022). However, Tinnitus
Loudness was more strongly correlated with Tinnitus Annoyance (t = 2.77, p
<0.0001, regression coefficient 0.49) and Tinnitus Life Effect (t = 2.77,
p<0.006, regression coefficient 0.10) than PTA threshold of the better ear.
In this three-factor linear regression model, a 1-dB increase in PTA threshold
of the better ear increased the Tinnitus Loudness score 0.022 units. Scores on Tinnitus Annoyance and Tinnitus
Life Effect had larger effects on Tinnitus Loudness than PTA. An increase in 1 VAS unit of Tinnitus
Annoyance was correlated with an increase of 0.49 VAS units of Tinnitus
Loudness while an increase of 1 VAS unit of Tinnitus Life Effect was associated
with an increase of 0.1 VAS unit of Tinnitus Loudness. Together, the inclusion of these three
factors in the linear regression model explained 52% of the variance in
Tinnitus Loudness as measured via VAS.
TABLE 1. Variables included in the final version of the stepwise linear regression
model for predicting VAS tinnitus loudness together with regression
coefficients, p values, and 95% CI values (n = 445).
PTA of the better ear
VAS of Tinnitus Annoyance
VAS of Effect of Tinnitus on Life
often ask whether the loudness of their tinnitus will increase if their hearing
gets worse. Our results suggest that tinnitus will likely get louder, but not
by very much. However, further longitudinal studies in
the same subjects are needed to test the hypothesis that tinnitus will get
louder as hearing loss increases. Because hearing loss increases with age and ototraumatic insults,
patients should be advised to avoid loud sounds in order to preserve their
hearing. However, prolonged daily use of
hearing protection is not recommended because it could increase the risk that
the tinnitus patient might develop hyperacusis (Aazh & Allott
2016; Formby et al. 2003). On
the other hand, hearing protection should be used when noise levels equal or
exceed noise safety regulations. Often
patients with tinnitus feel that they should protect their hearing to avoid
worsening their tinnitus. Hence, some
use hearing protection on a daily basis to prevent further hearing loss. These safety-seeking behaviors likely
contribute to tinnitus-related anxiety (Bennett-Levy et al. 2004; McManus et al. 2012). Safety-seeking
behaviors that restrict a patient’s life experience likely contribute to
tinnitus annoyance making the tinnitus “sound” even louder. Although there is
no cure for tinnitus, there are a wide range of rehabilitative approaches that
can minimize tinnitus annoyance and its impact on patient’s life (Aazh et al. 2016;
Tyler et al. 2015). Patients
who are less annoyed by their tinnitus or who feel tinnitus does not negatively
affect their life have lower tinnitus loudness ratings (Aazh & Moore
2016; Aazh et al. 2008).
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